{"data":{"id":"us-ok/okla.-stat.-tit.-59-59-360v2","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 59, § 59-360v2","heading":"Pharmacy benefits manager – Contractual duties to","body":"provider.\n\nA. The pharmacy benefits manager shall, with respect to\n\ncontracts between a pharmacy benefits manager and a provider,\n\nincluding a pharmacy service administrative organization:\n\nl. Include in such contracts the specific sources utilized to\n\ndetermine the maximum allowable cost (MAC) pricing of the pharmacy,\n\nupdate MAC pricing at least every seven (7) calendar days, and\n\nestablish a process for providers to readily access the MAC list\n\nspecific to that provider;\n\n2. In order to place a drug on the MAC list, ensure that the\n\ndrug is listed as “A” or “B” rated in the most recent version of the\n\nFDA’s Approved Drug Products with Therapeutic Equivalence\n\nEvaluations, also known as the Orange Book, and the drug is\n\ngenerally available for purchase by pharmacies in the state from\n\nnational or regional wholesalers and is not obsolete;\n\n3. Ensure dispensing fees are not included in the calculation\n\nof MAC price reimbursement to pharmacy providers;\n\n4. Provide a reasonable administration appeals procedure to\n\nallow a provider, a provider’s representative and a pharmacy service\n\nadministrative organization to contest reimbursement amounts within\n\nfourteen (14) calendar days of the final adjusted payment date. The\n\npharmacy benefits manager shall not prevent the pharmacy or the\n\npharmacy service administrative organization from filing\n\nreimbursement appeals in an electronic batch format. The pharmacy\n\nbenefits manager must respond to a provider, a provider’s\n\nrepresentative and a pharmacy service administrative organization\n\nwho have contested a reimbursement amount through this procedure\n\nwithin ten (10) calendar days. The pharmacy benefits manager must\n\nrespond in an electronic batch format to reimbursement appeals filed\n\nin an electronic batch format. The pharmacy benefits manager shall\n\nnot require a pharmacy or pharmacy services administrative\n\norganization to log into a system to upload individual claim appeals\n\nor to download individual appeal responses. If a price update is\n\nwarranted, the pharmacy benefits manager shall make the change in\n\nthe reimbursement amount, permit the dispensing pharmacy to reverse\n\nand rebill the claim in question, and make the reimbursement amount\n\nchange retroactive and effective for all contracted providers; and\n\n5. If a below-cost reimbursement appeal is denied, the PBM\n\nshall provide the reason for the denial, including the National Drug\n\nCode (NDC) number from, and the name of, the specific national or\n\nregional wholesalers doing business in this state where the drug is\n\ncurrently in stock and available for purchase by the dispensing\n\npharmacy at a price below the PBM’s reimbursement price. If the NDC\n\nnumber provided by the pharmacy benefits manager is not available\n\nbelow the acquisition cost obtained from the pharmaceutical\n\nwholesaler from whom the dispensing pharmacy purchases the majority\n\nof the prescription drugs that are dispensed, the pharmacy benefits\n\nmanager shall immediately adjust the reimbursement amount, permit\n\nthe dispensing pharmacy to reverse and rebill the claim in question,\n\nand make the reimbursement amount adjustment retroactive and in\n\neffect for all contracted providers for future claims billed.\n\nB. The reimbursement appeal requirements in this section shall\n\napply to all drugs, medical products, or devices reimbursed\n\naccording to any payment methodology, including, but not limited to:\n\n1. Average acquisition cost, including the National Average\n\nDrug Acquisition Cost;\n\n2. Average manufacturer price;\n\n3. Average wholesale price;\n\n4. Brand effective rate or generic effective rate;\n\n5. Discount indexing;\n\n6. Federal upper limits;\n\n7. Wholesale acquisition cost; and\n\n8. Any other term that a pharmacy benefits manager or an\n\ninsurer of a health benefit plan may use to establish reimbursement\nn Cost;\n\n2. Average manufacturer price;\n\n3. Average wholesale price;\n\n4. Brand effective rate or generic effective rate;\n\n5. Discount indexing;\n\n6. Federal upper limits;\n\n7. Wholesale acquisition cost; and\n\n8. Any other term that a pharmacy benefits manager or an\n\ninsurer of a health benefit plan may use to establish reimbursement\n\nrates to a pharmacist or pharmacy for pharmacist services.\n\nC. The pharmacy benefits manager shall not place a drug on a\n\nMAC list, unless there are at least two therapeutically equivalent,\n\nmultiple-source drugs, generally available for purchase by\n\ndispensing retail pharmacies from national or regional wholesalers.\n\nD. In the event that a drug is placed on the FDA Drug Shortages\n\nDatabase, pharmacy benefits managers shall reimburse claims to\n\npharmacies at no less than the wholesale acquisition cost for the\n\nspecific NDC number being dispensed.\n\nE. The pharmacy benefits manager shall not require\n\naccreditation or licensing of providers, or any entity licensed or\n\nregulated by the State Board of Pharmacy, other than by the State\n\nBoard of Pharmacy or federal government entity as a condition for\n\nparticipation as a network provider.\n\nF. A pharmacy or pharmacist may decline to provide the\n\npharmacist clinical or dispensing services to a patient or pharmacy\n\nbenefits manager if the pharmacy or pharmacist is to be paid less\n\nthan the pharmacy’s cost for providing the pharmacist clinical or\n\ndispensing services.\n\nG. The pharmacy benefits manager shall provide a dedicated\n\ntelephone number, email address and names of the personnel with\n\ndecision-making authority regarding MAC appeals and pricing.\n\nH. Any pharmacy benefits manager (PBM) that leases, rents, or\n\notherwise makes its provider network or contracts available to\n\nanother pharmacy benefits manager shall:\n\n1. Provide notice to all contracted providers of the lease\n\narrangement and the responsibilities of each party involved; and\n\n2. Provide contact information in each paid or rejected claim\n\nresponse that notifies the provider which contract the claim is\n\nadjudicating against, who is processing the claim, and a phone\n\nnumber to address provider issues; and\n\n3. Transmit the network reimbursement identification\n\ninformation with each claim response in NCPDP field 545-2F.\n\nI. Any pharmacy benefits manager (PBM) that leases, rents, or\n\notherwise makes its provider network or contracts available to\n\nanother pharmacy benefits manager shall not combine any Employee\n\nRetirement Income Security Act (ERISA) or government plans with any\n\nnon-ERISA or nongovernment plans.\n\nJ. 1. Effective rate contracting is hereby prohibited in all\n\nagreements between pharmacies or contracting agents acting on behalf\n\nof a pharmacy and a PBM or third-party payors. No PBM or third-\n\nparty payor shall enter into any contract that establishes payment\n\nfor services or medications based on an effective rate of\n\nreimbursement.\n\n2. Any PBM or third-party payor found to be in violation of\n\nthis section shall be subject to penalties, including, but not\n\nlimited to, fines, revocation of licensure, or other disciplinary\n\nactions.\n\nK. The provisions of this section shall not be waived, voided,\n\nor nullified by contract.","path":["OK Code","Title 59"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os59.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"8d58bfc46ad0afd961ebee7806c5b02a82a1525fe383ec9f4573a931e7e764d6","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-59-59-360v1","next":"us-ok/okla.-stat.-tit.-59-59-367.1"},"notice":"GroundRules: Original legal text. Not legal advice."}